laparoscopic cholecystectomy & its complications

1. COMPLICATIONS OF LAPAROSCOPIC
CHOLECYSTECTOMY
PRESENTER- Dr. Bashab Bijoy Roy
( 2nd year PGT).
MODERATOR- Dr.S.S.Bhattacharjee
(Assoc. Professor).

2. • Historical perspective
• First planned cholecystectomy in the world
was performed by Carl Langenbuch in 1882.
• First choledochotomy was performed by
Courvoisser in 1890.
• First iatrogenic bile duct injury was
described by Sprengel in 1891.
• Dr. Med Erich Muhe of Boblingen,
Germany, performed the first laparoscopic
cholecystectomy in 1985.
• Dr. Phillipe Mouret performed the first
doccumented laparoscopic Cholecystectomy in
the 1987

5. • In short - about
LAPAROSCOPIC
CHOLECYSTECTOMY

6. Indications of Lap chole
CHOLELITHIASIS Conditions unrelated
• Symptomatic cholelithiasis to gall bladder disease
(acute/chronic) Ac. Acalculous cholecystitis
• Porcelain gall bladder Biliary dyskinesia
with gall stones –risk of CA GB polyps, cholesterosis,
• Immunosuppression Adenomyomatosis
Complicated cholelithiasis congenital hemolytic anemia
• Gall stone pancreatitis sickle cell disease
• Choledocholithiasis with
cholangitis- (after cholangitis is resolved)

7. •Unable to tolerate gen. anestehsia

25. Complications of LAP cholecystectomy
• Trocar / veress needle injury
• Hemorrhage
• Biliary tree injury / CBD injury (most important)
• wound infection &/ or abscess
• Ileus
• Bile leak
• Gallstone spillage
• Deep vein thrombosis
• Retained CBD stone
• Conversion to open procedure.

26. • Incidence of injury by varess needle or trocher is
around 0.2%
Accidental intestinal injury /enterotomy:
1.By Hason’s technique(during open LAP access):-
can be repaired through the fascial incision.
2. By Varess needle:- no treatment is generally
necessary.
3. An electrosurgical injury to colon/duodenum
should be repaired with careful single / double
layer suture closure.
• Intestinal injury may occur during adhesiolysis, or
during dissection of gall bladder also.

27. • Hemorrhage :-
• During initial abdominal access:-
Large -vessel vascular injury can occur due to
inadequate anterior abdominal wall counter-
traction and
Excessive thrusting of the trocher by the
surgeon(trocher should be placed by a screwing
action- not by a plunging motion).
These may be lethal complications.
An unexplained retroperitoneal hematoma or
hypotesion should be treated immediately by
conversion to laparotomy.

28. • Excessive bleeding at the porta-hepatis region
should not be treated laparoscopically.
• Attempts to clip or cauterize significant bleeding
can lead to worsening of hemorrhage or hepatic
artery injury.
• Major bleeding needs conversion to open
cholecystectomy to ensure adequate control
without injury to CBD or hepatic arteries.
• Gall bladder bed bleeding- can be controlled by
elctrofulgration.
• If larger intrahepatic sinus has been entered-
hemostatic agents like microfibrillar collagen can
be placed in liver bed with pressure maintained by
a clamp.

29. Biliary tree / CBD injury

45. How to identify the important
structures > technique

49. What is
CRITICAL VIEW of SAFETY ??

54. Elephant Head or
Polyp on a Stalk appearance

56. What is
The infundibular technique ??

60. By visualisation-
how to differentiate between CBD
& Cystic duct

64. Classification of Bile duct injury

67. Stewart-Way classification

68. How to manage bile duct injuries

76. BILE LEAK
IMMEDIATE INTRA-OP
DIAGNOSIS
DELAYED DIAGNOSIS
MINOR INJURY MAJOR INJURY
PRIMARY REPAIR
WITH T-TUBE
NON - AVAILABILITY
OF
HEPATOBILIARY
SURGEON
CLIP OPEN DUCT
PUT A DRAIN
IV ANTIBIOTICS & REFER
EXPERIENCED
HEPATOBILIARY
SURGEON
AVAILABLE
ROUX-en Y
HEPATICO-
JEJUNOSTOMY
DRAINAGE
LOW OUTPUT HIGH OUTPUT
OBSERVE
RESOLVES
<5-7DAYS
ERCP
CONTINUED
DRAINAGE

77. CONTD..
ERCP
DUCT OF LUSCHKA LEAK CYSTIC DUCT STUMP LEAK SUSPECTED CBD
INJURY
SPHINCETEROTOMY
TRANSPAPILLARY STENT
WITH OR WITHOUT
SPHINCTEROTOMY
PTC TO DELIANATE ANATOMY
CONTROL OF DRAINAGE
REPAIR BY EXPERIENCED
HEPATOBILIARY SURGEON

78. STEPS TO AVOID BILE DUCT INJURY DURING
LAPAROSCOPIC CHOLECYSTECTOMY
OR
HOW TO PREVENT BILE DUCT INJURY

79. 1. Use a 30-degree laparoscope & high quality imaging
equipment.
2.Apply firm cephalic traction on the fundus & lateral traction
on the infundibulum so that the cystic duct is
perpendicular to CBD.
3.Disscet the cystic duct where it joins the GB.
4.Expose the “Critical View of Safety” prior to dividing the
cystic duct.
5.Give an intra-op time out before cutting/clipping.
6. Recognise a risky dissection…HALT!! Finish safely.
7.Convert to open procedure if the infundibulium cannot be
mobilized or if bleeding or inflammation obscures the
triangle of calot.
8.Perform the routine intraoperative cholangiography when
in doubt.
9.Understand potential abbernt anatomy.
10.Get help from experienced surgeon if in doubt.

83. Is choledocholithiasis a reason for
conversion??

84. • The incidence of choledocholithiasis in LC is
7.8% based on intra-op cholangiography.
• Previously in early 90’s , choledocholithiasis
used to be one of the major causes for
conversion into open method.
• But now in recent times with upgraded
techniques of ERCP, cholangiography &
endoscopy , its feasible to remove calculous of
biliary tract.

89. Deep vein thrombosis
High risk patients are:-
1.Previous DVT
2.Cancer
3.Obesity
4.Exogenous estrogens
5.Varicose veins

90. Projected operating time >2 hours
Age over 40 years
Recommended the addition of pharmacologic prophylaxis
(level III, grade C)
Calf length pneumatic compression devices can be used as prophylaxis
(lack of convincing Evidence in literature)

92. To conclude - summary
• Laparoscopic cholecystectomy is the gold standard surgery for
the gall bladder.
• Surgeon’s preference should dictate room setup,
patient’s positioning & instrument choice.
• No evidence of difference in safety in open vs closed
techniques during establishing abdominal access.
• Ultrasonic dissector is better than high frequency mono- polar
dissector to avoid complications.
• DVT prophylaxis is required only in high risk cases.
• Sharp instruments should not be moved intracorporeally
unless they are under dircet videoscopic vision
• The safety of LC requires correct identification of relevant
anatomy, critical view of safety and carefull dissection.
• Regular intra-op cholangiogram is useful in reducing the rate
of bile duct injury & prevention.
• Never hesitate to call a experienced surgeon in case of doubt .